Older Women’s Prehospital Experiences of Their First Myocardial Infarction

Behavioral delays in seeking care among post-acute myocardial infarction women: a qualitative study following percutaneous coronary intervention

Background

Cardiovascular diseases (CVD) remain the leading cause of mortality worldwide, with ischemic heart disease contributing significantly to female morbidity and mortality. Despite this, women often delay seeking medical help during acute myocardial infarction (AMI), leading to poorer outcomes compared to men.

Objective

To describe the early experiences of Italian women with AMI, focusing on behaviors that delay access to care.

Methods

Using a phenomenological approach, in-depth interviews were conducted with 22 women hospitalized in Campania, Italy, within five days of an AMI event and their Percutaneous Coronary Intervention (PCI), to capture vivid recollections of the experience. Thematic analysis was employed to identify key themes regarding risk behaviors and delays in care.

Results

Five key themes emerged: (1) vivid recollection of symptoms and experience, (2) lack of knowledge and risk perception of AMI, (3) decision-making process in seeking assistance, (4) influence of family and others on decision-making, and (5) post-AMI reflections on seeking medical care. Delays in seeking care stemmed from symptom misrecognition, social responsibilities, past healthcare experiences, and the role of family in decision-making, which either facilitated or hindered access to care.

Conclusion

The findings highlight the need for targeted educational interventions that address barriers specific to women in recognizing and responding to AMI symptoms. Gender-specific training for healthcare professionals is essential to ensure timely and appropriate care for women.

Students and physicians differ in perception of quality of life in patients with tumors of the upper gastrointestinal tract

Health-related quality of life (HRQoL) has recently gained importance as treatment options for tumors of the upper GI tract lead to improved long-term survival. HRQoL is often estimated by physicians even though their reliability and the impact of outside factors such as contact time and level of medical education is unclear. Therefore, in this study we investigated the correlation between physicians', students', and patients' assessment of HRQoL. 54 patients presenting with tumors of the upper GI tract were included and asked to fill out the standardized HRQoL questionnaires EORTC QLQ-C30 and QLQ-OG25. Attending physicians and medical students filled out the same questionnaires through estimation of patients' HRQoL. Correlation was assessed through Pearson's and Kendall's τb coefficients. Physicians' and patients' assessments correlated for one out of six of the functional and a third of the symptom scores. Students' and patients' assessments correlated for one third of the functional and two thirds of the symptom scores. Students tended to underestimate patients' symptom burden while physicians tended to overestimate it. Physicians failed to correctly assess several pathognomonic symptoms in this study. Students showed higher correlation with patients' symptoms than physicians. Even so, this adds to mounting evidence that shows the benefit of using patient-reported outcomes as a gold standard regarding HRQoL.

Experiences and perceptions of acute myocardial infarction patients with a prolonged decision-making phase of treatment seeking: A meta-synthesis

AIMS

To describe the experiences and perceptions of acute myocardial infarction (AMI) patients with a prolonged decision-making phase of treatment-seeking.

BACKGROUND

Previous attempts to reduce the treatment-seeking time of AMI have been less than optimal. Due to the coronavirus disease 2019 (COVID-19) pandemic, the situation of prehospital delay is possibly worse. Decisions to seek treatment are influenced by multiple factors and need individualised interventions. Understanding patients' external and internal experiences and psychological perceptions is essential.

DESIGN

Meta-synthesis.

DATA SOURCES

We searched PubMed, Embase, Cochrane Library, Web of Science, Scopus and four Chinese databases from inception to April 2022.

METHODS

We screened the retrieved articles with predetermined inclusion and exclusion criteria, and reviewed articles using Thomas and Harden's (BMC Medical Research Methodology, 2008 8, 45) qualitative thematic synthesis approach. The Joanna Briggs Institute critical appraisal tool for qualitative research was used to assess the quality of studies.

RESULTS

Twenty-one studies were included, identifying four themes and nine sub-themes. The four primary themes were difficulty recognising and attributing symptoms, attempt to act, unwillingness to change and self-sacrifice.

CONCLUSION

Deciding to seek treatment is a complex social and psychological process, which needs comprehensive interventions considering personal and sociocultural factors and factors related to the COVID-19 pandemic.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Details of interventions for decisions to seek treatment in AMI patients need to be further designed and evaluated.

IMPACT

Results would help healthcare professionals to implement individualised management of decision-making of treatment-seeking among AMI patients, and improve medical records of patients' prehospital experiences.

REPORTING METHOD

The Preferred Reporting Items for Systematic Reviews 2020 checklist was used to report the findings.

PATIENT OR PUBLIC CONTRIBUTION

Two AMI patients contributed to the data synthesis by giving simple feedback about the final themes.

Unusual Fatigue and Failure to Utilize EMS Are Associated With Prolonged Prehospital Delay for Suspected Acute Coronary Syndrome

BACKGROUND

Rapid reperfusion reduces infarct size and mortality for acute coronary syndrome (ACS), but efficacy is time dependent. The aim of this study was to determine if transportation factors and clinical presentation predicted prehospital delay for suspected ACS, stratified by final diagnosis (ACS vs. no ACS).

METHODS

A heterogeneous sample of emergency department (ED) patients with symptoms suggestive of ACS was enrolled at 5 US sites. Accelerated failure time models were used to specify a direct relationship between delay time and variables to predict prehospital delay by final diagnosis.

RESULTS

Enrolled were 609 (62.5%) men and 366 (37.5%) women, predominantly white (69.1%), with a mean age of 60.32 (±14.07) years. Median delay time was 6.68 (confidence interval 1.91, 24.94) hours; only 26.2% had a prehospital delay of 2 hours or less. Patients presenting with unusual fatigue [time ratio (TR) = 1.71, P = 0.002; TR = 1.54, P = 0.003, respectively) or self-transporting to the ED experienced significantly longer prehospital delay (TR = 1.93, P < 0.001; TR = 1.71, P < 0.001, respectively). Predictors of shorter delay in patients with ACS were shoulder pain and lightheadedness (TR = 0.65, P = 0.013 and TR = 0.67, P = 0.022, respectively). Predictors of shorter delay for patients ruled out for ACS were chest pain and sweating (TR = 0.071, P = 0.025 and TR = 0.073, P = 0.032, respectively).

CONCLUSION

Patients self-transporting to the ED had prolonged prehospital delays. Encouraging the use of EMS is important for patients with possible ACS symptoms. Calling 911 can be positively framed to at-risk patients and the community as having advanced care come to them because EMS capabilities include 12-lead ECG acquisition and possibly high-sensitivity troponin assays.

Recognizing pain as an early warning symptom of ischemic cardiovascular disease: A qualitative artistic representation of the journey

Background: Understanding the experience of prodromal ischemic cardiac pain and associated symptoms through use of literary and visual art evokes heightened a wareness of the emotional journey.

AIMS

The aim of this study was to describe the initial early prodromal pain-related symptoms and feelings associated with adjusting to this new cardiac health concern and explore the subjective experience of coming to the realization and awareness of developing heart disease.

MATERIALS AND METHODS

This study is a secondary supplemental qualitative analysis, using an arts-based embodied layered exploration assisted to translate the experiences of 23 individuals' journeys through symptom recognition. The analytic process involved three iterative layers: qualitative descriptive analysis of participant pain narratives, interpretation with thematic poetry, and representation via visual art to evoke an aesthetic, heightened level of understanding of the data.

RESULTS

Denial and disbelief, encroaching pain and symptoms of heart disease, and self-recrimination were three themes that emerged from the data. Pain described by participants brought forward the emotional dimensions of the experience. Participants described their process of realization as a tumultuous time, fraught with feelings of vulnerability and uncertainty, where anger and self-effacing ridicule permeated their thoughts that were tempered with profound gratitude at survival.

CONCLUSION

Bridging the connection between science and art to disseminate awareness of the nature of living with cardiac-related prodromal pain and disease is novel. Providing invitation and entrance into an individual's pain experience through qualitative inquiry with use of arts-based approaches makes visible the emotional meaning of pain.

Typical and Atypical Symptoms of Acute Coronary Syndrome: Time to Retire the Terms?

Studies indicate that symptoms labeled as "atypical" are more common in women evaluated for myocardial infarction (MI) and may contribute to the lower likelihood of a diagnosis and delayed treatment and result in poorer outcomes compared with men with MI. Atypical pain is frequently defined as epigastric or back pain or pain that is described as burning, stabbing, or characteristic of indigestion. Typical symptoms usually include chest, arm, or jaw pain described as dull, heavy, tight, or crushing. In a recent article published in the Journal of the American Heart Association (JAHA), Ferry and colleagues addressed presenting symptoms in men and women diagnosed with MI and reported that typical symptoms in women were more predictive of a diagnosis of MI than for men. A critical question is, are there really typical or atypical symptoms, and if so, who is the reference group? We propose that researchers and clinicians either discontinue using the terms typical and atypical or provide the reference group to which the terms apply (eg, men versus women). We believe it is past time to standardize the symptom assessment for MI so that proper and rapid diagnostic testing can be undertaken; however, we cannot standardize the symptom experience. When we do this, we are at risk of having study results, such as those of Ferry and colleagues, that vary from prior evidence and could lead to what the authors hope to avoid: disadvantaging women in receiving expeditious diagnostic testing and treatment for acute coronary syndrome.

Gender differences in symptom misattribution for coronary heart disease symptoms and intentions to seek health care

Women are more likely to delay seeking care for coronary heart disease (CHD) symptoms than men. We tested whether this was because they are more likely to misattribute CHD symptoms. Data were collected in December 2016. Participants were 714 Amazon's Mechanical Turk (crowdsourcing marketplace) workers with US Internet Protocol (IP) addresses; 52% female (ages 35-77 years) made judgments about patients of their same gender described in vignettes. We used adjusted multivariable logistic, ordinal, and linear regression to test our hypotheses. Women had a higher odds of misattributing the symptoms of the target in the vignettes to non-cardiac causes than men (adjusted odds ratio [AOR] = 2.08, p < .001), despite having higher mean knowledge scores about CHD (4.49 vs. 4.03, p < .001) and rating their CHD risk as higher (25% more likely to get CHD vs. 19%, p = .025) than men. Women were also less likely than men to intend to seek care at an emergency department (b = -0.33, p = .024), and if they did intend to seek care, they were more likely to intend to wait to seek care (AOR = 2.37, p = .003). Symptom misattribution may partially account for women's lower likelihood of intending to seek care from an emergency department, which would be especially critical in emergency situations.

Symptom description in patients with chest pain-A qualitative analysis of emergency medical calls involving high-risk conditions

AIMS AND OBJECTIVES

To explore the symptoms descriptions and situational information provided by patients during ongoing chest pain events caused by a high-risk condition.

BACKGROUND

Chest pain is a common symptom in patients contacting emergency dispatch centres. Only 15% of these patients are later classified as suffering from a high-risk condition. Prehospital personnel are largely dependent on symptom characteristics when trying to identify these patients.

DESIGN

Qualitative descriptive.

METHODS

Manifest content analysis of 56 emergency medical calls involving patients with chest pain was carried out. A stratified purposive sampling was used to obtain calls concerning patients with high-risk conditions. These calls were then listened to and transcribed. Thereafter, meaning units were identified and coded and finally categorised. Consolidated criteria for reporting qualitative studies guidelines have been applied.

RESULTS

A wide range of situational information and symptoms descriptions was found. Pain and affected breathing were dominating aspects, but other situational information and several other symptoms were also reported. The situational information and these symptoms were classified into seven categories: Pain narrative, Affected breathing, Bodily reactions, Time, Bodily whereabouts, Fear and concern and Situation management. The seven categories consisted of 17 subcategories.

CONCLUSIONS

Patients with chest pain caused by a high-risk condition present a wide range of symptoms which are described in a variety of ways. They describe different kinds of chest pain accompanied by pain from other parts of the body. Breathing difficulties and bodily reactions such as muscle weakness are also reported. The variety of symptoms and the absence of a typical symptomatology make risk stratification on the basis of symptoms alone difficult.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the importance of an open mind when assessing patients with chest pain and the requirement of a decision support tool in order to improve risk stratification in these patients.

Absence of chest pain and long-term mortality in patients with acute myocardial infarction

Objective

Chest pain is the predominant symptom in patients with acute myocardial infarction (AMI). A lack of chest pain in patients with AMI is associated with higher in-hospital mortality, but whether this outcome is sustained throughout the first years after onset is unknown. Therefore, we aimed to investigate long-term mortality in patients hospitalised with AMI presenting with or without chest pain.

Methods

All AMI cases registered in the SWEDEHEART registry between 1996 and 2010 were included in the study. In total, we included 172 981 patients (33.5% women) with information on symptom presentation.

Results

Patients presenting without chest pain (12.7%) were older, more often women and had more comorbidities, prior medications and complications during hospitalisation than patients with chest pain. Short-term and long-term mortality rates were higher in patients without chest pain than in patients with chest pain: 30-day mortality, 945 versus 236/1000 person-years; 5-year mortality, 83 versus 21/1000 person-years in patients <65 years. In patients ≥65 years, 30-day mortality was 2294 versus 1140/1000 person-years; 5-year mortality, 259 versus 109/1000 person-years. In multivariable analysis, presenting without chest pain was associated with an overall 5-year HR of 1.85 (95% CI 1.81 to 1.89), with a stronger effect in younger compared with older patients, as well as in patients without prior AMI, heart failure, stroke, diabetes or hypertension.

Conclusion

Absence of chest pain in patients with AMI is associated with more complications and higher short-term and long-term mortality rates, particularly in younger patients, and in those without previous cardiovascular disease.

Test Selection for Women with Suspected Stable Ischemic Heart Disease

Ischemic heart disease (IHD) is the leading cause of death and disability among women in the United States. Identifying IHD in women presenting with stable symptoms and stratifying their risk for an IHD event can be challenging for providers, with several different tests available. This article is meant to serve as a practical guide for clinicians treating women with potentially ischemic symptoms. Evidence and American Heart Association (AHA) recommendations regarding test selection are reviewed, with a focus on the information to be gained from each test. We outline suggested courses of action to be taken in the case of a positive or negative test. Regardless of the initial test result, clinicians should view a woman's symptom presentation as an opportunity to review and modify her risk of cardiovascular events.

Predictors of pre-hospital delay in Hong Kong Chinese patients with acute myocardial infarction

BACKGROUND

The pre-hospital delay to seek care remains the most significant barrier for effective management of acute myocardial infarction. Many of the previous studies mainly took place in Western countries. Few data are available about the care-seeking behavior of Hong Kong Chinese.

AIM

The purpose of this study was to identify the predictors of pre-hospital delay in care seeking among Hong Kong Chinese patients with acute myocardial infarction.

METHODS

Adult Chinese patients ( n=301) with a confirmed diagnosis of acute myocardial infarction were recruited from the cardiac units of three regional hospitals in Hong Kong. Various socio-demographic, clinical, symptom presentation characteristics and patient perceptual factors were considered as potential predictors. Multivariate analysis was conducted to identify the independent predictors with pre-hospital delay in care-seeking among acute myocardial infarction patients.

RESULTS

Perceived barriers to care seeking constituted the most significant predictor for longer pre-hospital delay in acute myocardial infarction patients. Female gender was also significant in predicting longer delay, whereas a greater extent of symptom congruence and a greater extent of typical symptom presentation were significantly associated with a shorter delay. The final model accounted for 49.6% of the variance in pre-hospital delay as a whole.

CONCLUSION

The most prominent predictors of pre-hospital delay are modifiable in nature, including the perceived barriers to care seeking and symptom congruence. Other sociodemographic and clinical factors also influence patients' decision. Although these are non-modifiable, our findings provide important insight for educating high-risk individuals.

A qualitative study of younger men's experience of heart attack (myocardial infarction)

OBJECTIVES

The effects of heart attack, or myocardial infarction (MI), across psychosocial domains may be particularly acute in younger adults, for whom serious health events are non-normative. MI morbidity is declining in Western countries, but in England MI numbers have plateaued for the under-45 cohort, where approximately 90% of patients are male. Qualitative research on younger adults' experience of MI is limited, and no study has sampled exclusively under-45s. This study aimed to understand how a sample of men under 45 adjusted to and made sense of MI.

DESIGN

Qualitative research design based on semi-structured in-depth interviews.

METHODS

Ten men aged under 45 who had experienced MI in the past 3-6 months were purposively recruited and interviewed. Interviews were transcribed verbatim and analysed using interpretative phenomenological analysis.

RESULTS

Seven superordinate themes were identified. This article focuses in depth on the three most original themes: (1) 'I'm less of a man', which described experiences of losing 'maleness' (strength, independence, ability to provide) post-MI; (2) 'Shortened horizons', which covered participants' sense of foreshortened future and consequent reprioritization; and (3) 'Life loses its colour', describing the loss of pleasure from lifestyle-related changes.

CONCLUSION

Themes broadly overlapped with the qualitative literature on younger adult MI. However, some themes (e.g., loss of 'maleness' post-MI, and ambivalence towards MI risk factors) appeared unique to this study. Themes were also discussed in relation to risk factors for anxiety and depression and how this might inform clinical care for a younger, male population. Statement of contribution What is already known on this subject? Myocardial infarction (MI) morbidity is not declining in England for under-45s. Adjustment to MI is particularly challenging for younger adults, perhaps because it is non-normative. However, little is known about the experience of MI in younger adults. What does this study add? This is the first qualitative study to sample MI patients exclusively under 45, thereby mapping to epidemiological trends. Further support is provided for some themes identified in the existing young adult MI literature. New themes are identified here which can provide insights relevant to clinical care in this population.

A Qualitative Study of Symptom Experiences of Women With Acute Coronary Syndrome

BACKGROUND

Most studies show that women with symptoms of acute coronary syndrome (ACS) delay seeking care longer than men do. Contributing factors include women being more likely to experience diverse symptoms, to experience symptoms that do not match preexisting symptom expectations, to interpret symptoms as noncardiac, and to minimize symptoms until they become incapacitating.

OBJECTIVE

The aim of the study is to identify factors influencing women's ability to recognize and accurately interpret symptoms of suspected ACS.

METHODS

This qualitative study used in-depth interviews with 18 women diagnosed with ACS to determine how they recognized, interpreted, and acted on symptoms. An interview guide developed from the author's initial research was used to provide structure for the process.

RESULTS

All of the women went through a process of recognizing and interpreting their symptoms. Eight women had symptoms arise abruptly. Most of these women recognized a change immediately, "knew" to go for treatment, and did so quickly. Three women had vague symptoms that started slowly, converting unexpectedly to intense symptoms prompting them to seek care urgently. The remaining 7 women had evolving symptoms, were more likely to interpret symptoms as unrelated to their heart, and avoided disclosing symptoms to others. Despite recognizing that the situation may be serious, women with evolving symptoms adopted a wait-and-see approach.

CONCLUSION

Women with less severe, intermittent, or evolving symptoms are at increased risk for delayed presentation, diagnosis, and treatment for ACS. These women should be targeted for educational and behavioral interventions.

Testing a Model to Reveal the Predictive Mechanism of Care-Seeking Decisions Among Patients With Acute Myocardial Infarction

BACKGROUND

Extensive research has been conducted to examine the factors affecting care-seeking decisions in patients with acute myocardial infarction (AMI). Such a decision-making process is multifactorial, and its underlying mechanism is yet to be determined.

OBJECTIVES

Our aim was to test a theoretically integrated model to identify the mechanisms underlying patients' care-seeking decisions in the context of AMI.

METHODS

On the basis of both empirical and theoretical evidence, we proposed that patients' care-seeking decisions are driven by 2 sequential perceptual-cognitive processes concerned with illness labeling and interpretation, as well as the contextual influences of perceived barriers to care seeking and cues from others. A sample of 301 patients was recruited to test this model using structural equation modeling.

RESULTS

The model testing revealed good fit with the data (χ = 38.48, df = 30, P = .72; root-mean-square error of approximation = 0.03, normed fit index = 0.96, nonnormed fit index = 0.98, and comparative fit index = 0.99) and explained 46% of the variance in AMI care-seeking delay. Successful action relied on whether patients could correctly attribute the symptom experience to AMI, were aware of their own susceptibility to the condition, and had a good understanding of how the disease manifested itself. Lowering perceived barriers and positive cues from others in advising care seeking played favorable roles to promote care-seeking behaviors.

CONCLUSIONS

This integrative theoretical model is shown to be valid in explaining care-seeking delay among AMI patients and can guide the development of interventions to promote appropriate care-seeking behaviors among high-risk individuals.

Pre-hospital delay in patients with first time myocardial infarction: an observational study in a northern Swedish population

Background

In myocardial infarction (MI), pre-hospital delay is associated with increased mortality and decreased possibility of revascularisation. We assessed pre-hospital delay in patients with first time MI in a northern Swedish population and identified determinants of a pre-hospital delay ≥ 2 h.

Methods

A total of 89 women (mean age 72.6 years) and 176 men (mean age 65.8 years) from a secondary prevention study were enrolled in an observational study after first time MI between November 2009 and March 2012. Total pre-hospital delay was defined as the time from the onset of symptoms suggestive of MI to admission to the hospital. Decision time was defined as the time from the onset of symptoms until the call to Emergency Medical Services (EMS). The time of symptom onset was assessed during the episode of care, and the time of call to EMS and admission to the hospital was based on recorded data. The first medical contact was determined from a mailed questionnaire. Determinants associated with pre-hospital delay ≥ 2 h were identified by multivariable logistic regression.

Results

The median total pre-hospital delay was 5.1 h (IQR 18.1), decision time 3.1 h (IQR 10.4), and transport time 1.2 h (IQR 1.0). The first medical contact was to primary care in 52.3 % of cases (22.3 % as a visit to a general practitioner and 30 % by telephone counselling), 37.3 % called the EMS, and 10.4 % self-referred to the hospital. Determinants of a pre-hospital delay ≥ 2 h were a visit to a general practitioner (OR 10.77, 95 % CI 2.39–48.59), call to primary care telephone counselling (OR 3.82, 95 % CI 1.68–8.68), chest pain as the predominant presenting symptom (OR 0.24, 95 % CI 0.08–0.77), and distance from the hospital (OR 1.03, 95 % CI 1.02–1.04). Among patients with primary care as the first medical contact, 67.0 % had a decision time ≥ 2 h, compared to 44.7 % of patients who called EMS or self-referred (p = 0.002).

Conclusions

Pre-hospital delay in patients with first time MI is prolonged considerably, particularly when primary care is the first medical contact. Actions to shorten decision time and increase the use of EMS are still necessary.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0271-x) contains supplementary material, which is available to authorized users.

Women's experiences during myocardial infarction: systematic review and meta-ethnography

AIMS AND OBJECTIVES

The aim of this review is to identify, analyse and synthesise existing knowledge concerning female experiences during myocardial infarction.

BACKGROUND

There is a lack of knowledge about women's experiences during myocardial infarction, and a meta-synthesis is needed to synthesise existing evidence.

DESIGN

A systematic review and meta-ethnography.

METHOD

A systematic review was undertaken in September 2013. Four databases were searched. Grey literature and reference lists were screened for relevant studies. Four hundred and eighty-one papers were identified and 14 were included. The method of Noblit and Hare was used in the process of conducting this review and meta-ethnography.

RESULTS

Three themes were identified. 1. 'Feeling the changes in my body', 2. 'Understanding the changes in my body' and 3. 'Acting on the changes in my body'. The majority of women did not experience their body changes as being severe and threatening. Therefore, the women chose to wait or self-medicate before consulting others. The women who initially experienced the symptoms related to myocardial infarction as being severe and threatening, chose to consult others earlier than the majority of women.

CONCLUSION

Women's experiences and interpretation of body symptoms during myocardial infarction vary. Most commonly women do not initially recognise their body symptoms as being severe and life threatening. The theory of Merleau-Ponty's 'current and habituated body' is relevant for explaining women's ways of understanding and acting on their body changes during myocardial infarction.

RELEVANCE FOR CLINICAL PRACTICE

This review is relevant in a preventive and rehabilitating perspective for professionals working in health care. It helps professionals to understand women's experiences during myocardial infarction, optimises their ability to suspect myocardial infarction and teach women to react on these body changes.

Women's help-seeking behaviour during a first acute myocardial infarction

Studies indicate that the time from onset of symptoms to medical treatment has decreased in acute myocardial infarction (AMI). However, there are still variations indicating that women wait longer than men before making the decision to seek medical care. Multidimensional factors hindering and facilitating the decision have been identified in previous studies, though few have fully explored how social context affects women's expectations, interpretations and actions and so influences the decision-making process. The aim of this study was therefore to identify how women's experiences interacted and influenced the decision to seek medical care at their first AMI. Seventeen women, aged 38-75 years, were interviewed, at home or in the hospital, between June 2011 and May 2012. Grounded theory was used as a method, and data collection and analysis were carried out simultaneously. The results showed that before deciding to seek medical care, these women went through three defined but interrelated processes that together hindered their normal activities and made them act according to existential needs. The women's experiences of the progression of the disease, in terms of both symptoms and time, were very different, so they sought medical care at different times, sometimes life-threateningly late and sometimes before developing an AMI. Three mechanisms had to coincide if the women were to receive medical care. First, the women had to acknowledge their symptoms as something more than common bodily changes. Second, the healthcare system had to be accessible when the women made their decision to seek care. Third, the women must have come into contact with healthcare providers when the heart muscle had taken enough damage to measure.

The Process of Care-seeking for Myocardial Infarction Among Patients With Diabetes

BACKGROUND

People with diabetes have a higher risk for myocardial infarction (MI) than do people without diabetes. It is extremely important that patients with MI seek medical care as soon as possible after symptom onset because the shorter the time from symptom onset to treatment, the better the prognosis.

OBJECTIVE

The aim of this study was to explore how people with diabetes experience the onset of MI and how they decide to seek care.

METHODS

We interviewed 15 patients with diabetes, 7 men and 8 women, seeking care for MI. They were interviewed 1 to 5 days after their admission to hospital. Five of the participants had had a previous MI; 5 were being treated with insulin; 5, with a combination of insulin and oral antidiabetic agents; and 5, with oral agents only. Data were analyzed according to grounded theory.

RESULTS

The core category that emerged, "becoming ready to act," incorporated the related categories of perceiving symptoms, becoming aware of illness, feeling endangered, and acting on illness experience. Our results suggest that responses in each of the categories affect the care-seeking process and could be barriers or facilitators in timely care-seeking. Many participants did not see themselves as susceptible to MI and MI was not expressed as a complication of diabetes.

CONCLUSIONS

Patients with diabetes engaged in a complex care-seeking process, including several delaying barriers, when they experienced symptoms of an MI. Education for patients with diabetes should include discussions about their increased risk of MI, the range of individual variation in symptoms and onset of MI, and the best course of action when possible symptoms of MI occur.

Getting to Normal: Women's Experiences Self-Managing Their Perceived Blood Pressure Changes

BACKGROUND

In the United States, nearly 25% of all women older than 20 years have hypertension (HTN). Nearly 30% to 50% of persons with HTN experience symptoms attributed to high blood pressure (BP). Women with hypertensive symptoms may connect their symptoms to perceived BP changes and may be using their perceptions about BP changes to guide their HTN self-management. There is limited research about perceived BP changes or their use in self-management.

OBJECTIVE

The purpose of this qualitative study is to describe the experiences of women with HTN self-managing their perceived BP changes.

METHODS

van Manen's phenomenology methodology and method guided the inquiry. Women with HTN who believed they could tell when their BP changed based on their symptoms were recruited from community settings and were interviewed once with a semistructured guide. Interviews were digitally recorded and professionally transcribed. Textual data were analyzed using thematic analysis to identify major themes.

RESULTS

Seven black and 6 white women comprised the study sample. Participants were middle aged (mean [SD], 50.5 [9.62] years), were experienced in living with HTN (mean [SD],10.76 [9.50] years), had at least a high school education, and had a limited annual income (93% <$24 000). One central theme ("getting to normal") and 4 subthemes (i.e., "I can tell," "tending to it," "the wake-up call," and "doing it right") were discovered in the data. The themes depict a process of episodic symptom-driven and day-to-day actions that the participants used to get their BP to normal.

CONCLUSIONS

The study is significant as new knowledge was discovered about how women perceive their BP changes and use them to guide self-management. This study contributes to clinical practice through suggestions for improving patient assessments. Results serve as a foundation for further research of the self-management of BP changes and developing belief-based interventions with the potential to improve BP control.

Dealing with coronary artery disease in early encountering: a qualitative study

BACKGROUND

The prevalence of cardiovascular diseases is rising in industrial and developing countries. Coronary Artery Disease (CAD) is the most common cardiovascular disease. Thus, understanding the signs and risk factors of CAD from the patients' perspective and their ways of dealing with this disease is of vital importance.

OBJECTIVES

This qualitative study aimed to explore the Iranian patients' viewpoints about CAD and how they dealt with it in their first encounter.

PATIENTS AND METHODS

This study was a qualitative content analysis conducted on 18 patients with CAD. The data were collected through semi-structured interviews. Initially, purposeful sampling was performed followed by maximum variety. Sampling continued until data saturation. Then, all the interviews were recorded and transcribed verbatim. After all, the data were analyzed by constant comparative analysis using MAXQUDA2010 software.

RESULTS

The themes manifested in this study included "invasion of disease" with subthemes of "warning signs" and "risk factors" and "confrontation strategies" with subthemes of "seeking for information", "follow-up", and "control measures".

CONCLUSIONS

The results of this study described the patients' perceptions of CAD and how they dealt with this disorder in early encountering. Based on the results, physicians and nurses should focus on empowerment of patients by facilitating this process as well as by educating them with regards to dealing with CAD.

Health care contact is higher in the week preceding a first myocardial infarction: A review of medical records in Northern Sweden in 2007

BACKGROUND

Prodromal symptoms before myocardial infarction (MI) are common, but there are limited data regarding health care contact prior to the acute onset of MI and the impact of gender on early presentation to health care.

AIMS

The purpose of this study was to describe and analyse prodromal symptoms reported in medical records and study health care contact in the week before the acute onset of MI in comparison to the general population.

METHODS

From the Northern Sweden MONICA Study we accessed the medical records of 359 patients aged 32-74 years with a first MI in the county of Norrbotten in 2007. We identified those patients' health care contact during the seven days before the MI and compared them with the weekly number of contacts in the general population aged 45-74 years in the county during 2007.

RESULTS

We found that 23.1% of the women and 17.6% of the men had at least one contact the week before the MI. With the exception of the 14 women aged 45-55 years, health care consumption in both women and men in all age groups between 45- 74 years of age was 75%-165% higher in the week prior to the MI than in the general population of the same ages. In the first health care contact, pain-related symptoms were most frequent (43%), and fatigue was present in 8% of patients. There were no differences between women and men in health care consumption or presenting symptoms.

CONCLUSION

Both women and men with a first MI are in contact more frequently than the general population in the week prior to the event.

Thoughts and behaviors of women with symptoms of acute coronary syndrome

OBJECTIVE

Women delay seeking care for symptoms of acute coronary syndrome (ACS) because of atypical symptoms, perceptions of invulnerability, or keeping symptoms to themselves. The purpose of this study was to explore how women recognized and interpreted their symptoms and subsequently decided whether to seek treatment within the context of their lives.

METHOD

Grounded theory was used to provide the methodological basis for data generation and analysis. Data were collected using in-depth interviews with 9 women with ACS.

RESULTS

All participants went through a basic social process of searching for the meaning of their symptoms which informed their decisions about seeking care. Stages in the process included noticing symptoms, forming a symptom pattern, using a frame of reference, finding relief, and assigning causality. The evolving MI group (n = 5) experienced uncertainty about bodily cues, continued life as usual, until others moved them toward care. The immediately recognizable MI group (n = 4) labeled their condition quickly, yet delayed, as they prepared themselves and others for their departure.

CONCLUSIONS

All women delayed, regardless of their ability to correctly label their symptoms. Education aimed at symptom recognition/interpretation addresses only part of the problem. Women should also be educated about the potential danger of overestimating the time they have to seek medical attention.